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This month's feature affects just about every surfer on the planet.
Whether you're in the water all day or grinding it out at school or work, one thing is for sure: you or someone close to you has a lower back that's an issue. It's one of the most common areas of injury we seek help for in our Western health-care system. (Interesting to note: societies that do not sit in chairs as much as we do, have a much lower incidence of low back injury.)
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You'd be surprised to know that most cases of back injury are caused by seemingly small problems (muscle and movement imbalances), which by themselves may not seem like a major threat to your health and well being. But you may also be shocked to learn most of us are really ticking time bombs, and are just a twist, a reach behind the car seat, or throwing a minor tweaky little cuttie that just didn't feel right away from big-time pain. Which inevitably turns into time out of the water, wondering if your back will ever feel normal -- and will I ever be able to surf again? Low back pain causes and symptoms can vary dramatically from getting rag-dolled at Pipe, to even just feeling a slight little twinge on a small wave, from the feeling of being hit with a sledge hammer, stabbed with an ice-pick, or exposed to a ungrounded electric current, to a minor spasm that slowly starts to tighten up to the point where you find yourself having to take five minutes to stand upright after driving or sitting. Low back injuries come in all shapes and sizes and have fancy names like, spinal stenosis, facet syndrome, disc herniation or sciatica. The bottom line is that no matter the specific part of the lower back you injure, what really is important in the end game is how you learn to control it. I want to be clear about something here: please notice I did not say CURE it. If there was a cure, everyone could do the same or similar treatments, and low back injuries would not be in the top five reasons why people go see a doctor. "...you must treat the person and the cause, not the just the back or the symptoms."
--DR. TIM BROWN
After 25 years treating and training athletes with low back injuries, what I have learned is that you must treat the person and the cause, not the just the back or the symptoms. This is not to say that our first goal isn't to get you out of pain, to the contrary. The most important factor in healing any biomechanical injury is regaining proper movement, and in order to get you moving, first we have to reduce the inflammation and pain. Learning to read your body and becoming "aware" is something we must all master. You must learn to listen to your body and react accordingly. We tell our athletes: "listen for the whisper of abnormal muscle tension and/or difficulty in moving with balance, before you hear the scream of illness or injury." Until the surfer becomes stable (stability before strength) in their core and posture, they will possess little or no control of their lower back health -- ever. And over time, surfing will just become too hard for you to do. You will end up losing the stoke because you can't seem to pop up quickly and smoothly as you did before. Before you know it, you'll find it easier to roll with the path of least resistance, which usually means deciding to sacrifice your movement because of pain and the thought that you don't want to mess up your back. When in fact it was never really about the back, as much as it is about you and doing the work it takes to remain loose, balanced, and stable, so surfing becomes easier not harder. Surfing, like health, is and always has been a by-product of who you are and how you move. What are most common low back injuries in surfing? The great majority of lower-back injuries are sprains and strains of the spine and adjacent soft tissues, i.e., the muscles, tendons, and ligaments. The lumbar region is susceptible to strain because it is the area of great compensatory movement in relation to the thoracic spine above and the pelvis below. There are five motion segments in the lumbar spine, each of which are made up of the disc in-between, and a pair of facet joints behind. The spine ends with the sacrum, which is connected to the pelvis by paired sacroiliac (SI) joints. The facet joints and the SI joints are supported by ligaments, which can be torn if excessive motion is imposed on them, which is to say these joints can be sprained. The disc is unique in that it has a central nucleus made of fibro-gelatinous material not unlike heavy jelly surrounded by concentric rings of dense collagen fibers similar to the canvas layers around a fire hose. As I am sure you have heard, tears in the fibrous ring, called the annulus, can occur through which the nucleus (jelly) can protrude, leading to back pain, inflammation, and radicular symptoms with or without sciatica. The types of motion that trigger most sprain strains and disc-related conditions are usually associated with twisting (rotation) and bending forward at the waist (flexion), although extreme arching backwards can cause compression, irritation, and even fracture of the facet joints. As surfers pump for more speed, crank turns that cause more abrupt directional changes, and boost for bigger air, the risk for sustaining injuries to the low back secondary to over-rotation and flexion goes up. This doesn't mean that we shouldn't strive for more aggressive, high-power surfing, but it does mean that the surfer needs to prepare his or her body to withstand the stresses of surfing with greater speed. As the old adage states, "an ounce of prevention is worth a pound of cure." As a surfer, you're never too young or too old to be proactive about stability, strength, and flexibility, which will prevent most injuries, and lead to a quicker recovery if an injury does occur. How do low back injuries occur? Lumbar injuries occur when the tolerance of the structures (ligaments, disc, muscles) that support spine is exceeded. These injuries fall into two main categories: Macrotrauma -- a one time event where the tissues are injured -- or Microtrauma -- small stresses that over time lead to an injury. The low back injury typically occurs because the lumbar spine has been forced to do too much, and had to work too hard. The lumbar spine is a small chain of five vertebrae, as compared to the very stiff ribcage above and the pelvis/hips below. The lumbar spine is the ultimate compensator for motion. If your hips and pelvis don't rotate enough, you lumbar spine will rotate more to get you there. You only get one spine, don't trash it! (For those of you who are overachievers, here's a study provided by Mark Kazuki PT that shows how hip range of motion imbalance is associated with back pain: Ellison et al. Phys Ther. 1990 Sep; 70 (9): 537-41) What should I do if my back is bothering me? See a Healthcare practitioner who specializes in Functional vs. Structural care. It is often very difficult at times to narrow a back injury down to one structure. We also know that imaging is not the end-all-be-all to diagnosis. Some studies (examples below) point out that degeneration, disc bulging, disc protrusion, disc herniation, foraminal stenosis were all common MRI findings in people without back problems. (Boden S et al., J bone joint surg Am. 1990 Mar; 72(3): 403-8 Boden S et al., J Bone Joint Surg Am. 1990 Sep; 72(8): 1178-84 Jensen M et al., N Engl J Med. 1994 Jul 14; 331(2):69-73) The clinical exam needs to correlate with image. More importantly, the clinical exam needs to find the contributing factors that have led to the anatomic changes. A good rehab program will address posture, core, faulty movement patterns, and deficits in flexibility, strength, and coordination. What are some of the best ways to prevent Back pain/injuries? This is where the early Surfline Health + Fitness features provided the foundations: flexibility, stability, endurance, and then strength. The best way to prevent a back injury is to limit the compensatory nature of low back. This is done by improving stability in the low back as well as improving the mobility of the ribcage and hips. 1. The use of foam rollers for the rib cage and hips help to improve soft tissue and joint mobility. 2. The hips should also be stretched consistently and any imbalance should be addressed. Avoid overstretching the low back, Stuart McGill PhD a lumbar spine expert, states that "there is little evidence that shows that increasing back flexibility decreases injury risk." 3. Training the low back in the neutral position for functional tasks and during core exercises will make your back more stable. The neutral position is where you have the least amount of stress on either side of your spinal vertebrae. Training in this position will put the least amount of stress on your spine and protect your back. 4. Functional retraining during daily tasks will also help to reduce the repetitive micortrauma to your spine. 5. Stability and endurance of the deep stabilizers is also extremely important. The deep abdominals, deep lumbar multifidus, and glutes provide stability and support to the lumbar spine throughout movement and provide important protection from the high forces placed on the body during surfing. Note: Stability and endurance need to be trained slightly differently but are both equally important in these muscle groups. Stability is imperative so that the deep support system can cope with one off forces of a high velocity maneuver. Endurance is equally important in this muscle group to cope with prolonged postures involved in paddling, sitting on the board and our more mundane activities of daily living and work. How do I train to stabilize my core and posture to prevent back pain and injury? Core conditioning is a big part of the program. If you're training for an hour and a half, 30 min or so should be core-based movement and exercises. The goal is to correct a static imbalance (postural alignment) or dynamic dysfunction (basic movement like a faulty squat) that can lead to or increase the risk of either a repetitive motion injury (wear and tear) or a single incident accident (one big slam or tweak.) What follows are examples of simple movements and stretches to wake up, mobilize and stabilize your core for greater control and support of lower back. [NOTE: If you have back pain, and you are doing the right exercises for your condition, the pain and symptoms will decrease in intensity, frequency and duration, and your pain will begin to be more focused and localized to smaller area.] 1. STRETCHES (Use a doorway/tree to stretch tight hamstring and glutes at multiple angles while back is supported. Perhaps on an ice pack.) A. Bring your right leg up the wall with opposite leg bent, gently stretch your right hamstring (30 secs -1min), making sure you feel no pressure or pain in your back. B. Then bring your left foot over your right knee. Feel the stretch in your left outer glute. To adjust to increase the tension of the stretch, slowly slide the right foot of the straight leg, down the tree until you feel the gentle stretch in your l glute. Hold for 30 secs - 1 min. while slowly breathing through your nose and into the belly. Also be sure you keep your back supported on the ground don't uncomfortably overstretch the hamstring which is up the wall. C. Now move the one foot midway across the shin and stretch another 30 secs-1min. If you can't get your foot over your knee without pain or your back coming off the ground, you may not be ready for this stretch. (As a note: if you have a disc or nerve related condition, stretching will sometimes make things worse so check with your physician if you have a history of low back injury before attempting any of the mobility and stability exercises.) 2. BRIDGES (Tones underused muscles that must support your core -- hips, pelvis and low back.) A. Supine bridge: Lie on a mat face up with your arms at your sides. (link.) Bend your knees and bring your heels against your butt. Feet are flat on the floor. Squeeze your glutes, push through your heels and lift your hips off the mat as high as they can go. Breathe out as you lift and pull in your abs. Hold the position for 1 to 3 seconds. Lower your hips as you inhale. Repeat 11 times. B. Moderate bridge Start in the same position as in the first section. Lift your right foot off the floor. Push through your left heel, lift your hips and straighten your right leg in the air. Hold for 2 seconds. Bend your right knee, but do not put your foot back on the ground. Lower your hips. Switch legs and keep going for another 10 repetitions. C. Advanced bridge or ball bridge Lie on a stability ball and put your hands on your hips. Squeeze your glutes and abs as you make a bridge with your body parallel to the floor and with your shoulders and neck only on the ball. Put your feet flat on the floor and hip width apart. Hold for 3 seconds. Lower your hips about halfway to the floor without allowing your feet or the ball to move. Raise your hips back up by squeezing your gluts and hold the bridge position again. Do 10 to 15 reps. While controlling and bracing your core through the whole exercise, slowly lift your hips off the ground and control and hold each rep for a 3 second count 3. TIBETAN RITE NUMBER THREE: (Opens and energizes muscles you shorten and overuse daily while relaxing the low back.) Kneel on floor with lower legs extended behind you, toes curled under and rest of body erect. Grasp your thighs with your hands, thumbs facing forward and breathe in through your nose and into the belly. Breathe out through nose as you gently roll your head and neck forward , tucking your chin into chest. Breathe in slowly and deeply as you lean backward, angling torso over lower legs. As you spine arches, your head follows, bending back gently as far as it goes without stressing your neck or lower back. Breathe out and return to starting position. Breathe in and repeat 3-7 times. Feel the stretch in the front of your neck and chest and front of upper thighs and hips -- not in your lower back. 4. SUPERMAN: (Connects and coordinates muscles of upper and lower back.) While laying face down, control and engage, bracing your core through the whole exercise. Use your hip (not your low back) to raise your leg/foot slowly and gently off the ground, and contract your glute for a three-second count. Now try it again but also lift your opposite arm using your back of shoulder and middle back muscles and hold for 3-7 seconds. If you feel it in your lower back, stop! Do not lift leg or arm so high off ground. Try again. If painful do not continue this exercise. 5. ASSISTED SQUATS: (Increasing ankle and hip mobility decreases stress on your low back and knees and relaxes hip flexors.) While controlling and bracing your core through the whole exercise, keep your weight on your heels and your knees behind your toes, lean back and squat gently and slowly, in a comfortable range of motion. Do 5-7 reps holding for 5-7 seconds at bottom of move, then push up through your heels, keeping chest tall and head up. Alternate by doing longer holds for up to one minute at bottom of squat. Use the table or doorknob for support and balance until you can let go and comfortably hold squat with butt on ankles and weight balanced equally over the whole foot for a few minutes at a time. +++ Like many things in life, we tend to push our problems to the back. This tension can be both physical and emotional. A healthy spine is crucial to surfing and feeling good. If there is any kind of pain, rigidness or dysfunction in the back, the body will avoid using that part. When you avoid using an area, you start moving in parts instead of as a whole unit, which inevitably creates bad technique in and out of the water. Bad backs aren't caused by age or genetics alone; they're usually caused by faulty movement patterns and lack of awareness. This can always be changed. No matter what diagnosis your low back injury is given, one theme continues to emerge from the latest in clinical and scientific research. To finally gain control over your pain and symptoms, (no matter what your personal choice of care, natural or traditional or both) you must find a Healthcare professional who takes a functional, whole-body approach and demands you participate actively in your care. You must be determined to work hard to understand not only your body, but the idea that what you do everyday and the way your body moves, many times create the very muscle imbalances which cause instability in your core and posture, and eventually lead to low back pain. I have no doubt these major factors must be at the top of your list in the quest to control the beast known as the low back injury. +++ Surfline H&F Team contributors for this feature were: Tim Brown D.C. tbsportscare@yahoo.com Sten Kramer, M.D. sten@kramermedical.com Matt Griggs, CSCS matt@spartanmanagement.net Mark Kozuki, P.T. mark@opswellness.com Matt Gray P.T. mp_gray@hotmail.com Peter Park, CSCS peter@sbplatinumfitness.com Doug Andersen, D.C. andersenchiro@ John Pecora D.C. Jpdc1@hotmail.com +++ (To contact Dr. Tim Brown, D.C. directly, check out DrBrownDesigns.com. Stay tuned to Surfline for monthly features by Dr. Tim Brown and his staff of experts. Click here to go to Dr. Tim Brown's blog page.) +++ DISCLAIMER: The information provided in Surfline Health & Fitness is for informational purposes only and is not intended as a substitute for advice from your physician or other healthcare professional. You should not use this information for the diagnosis or specific treatment of any health problem or for prescription of any medication or other treatment. You should consult with a healthcare professional before starting any diet, exercise, or supplemental program, before taking any medication, or suspect you might have a health problem. You should not stop taking any medication and/or should not discontinue any prescribed treatment or exercise without first consulting your physician. The opinions expressed in the Health and Fitness department are of the author and the author alone. Surfline does not endorse any specific product, service or treatment. MORE HEALTH + FITNESS MORE SURF NEWS SURFLINE HOME PAGE |
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Comments: (23) Add Your Comment
Richie 12/22/2009 06:16 PM
Awesome article boys!Suffering from a large potrussion L4-L5.Stetching and core strengthening are key.Always looking for new & improved ways to stetch.Need more hip flexor stretches. Aloha&mahalo
Dr. Tim Brown 12/12/2009 09:01 PM * PREMIUM MEMBER - Real Name
SURFMORE:
Please go see Paul Hiniker, CSCS. in San Clemente. Hook up with him at hini_loc@yahoo.com. He trains Taylor Knox and other elite athletes and is all about education, mobility and stability and function! G luck! Dr TB
Dr. Tim Brown 12/12/2009 08:55 PM * PREMIUM MEMBER - Real Name
Andrew, Your girlfriend can be helped a lot. It is important that she first sees a good sports chiropractor, physical therapist who specializes in the functional evaluation and treatment of scoliosis and who is keen on teaching her how she can best learn to make the best choices in shoes, chairs, beds, workouts, stretches, even foods can effect the symptoms of scoliosis (health is what you eat, think and do!) Thanks! Dr TB
Dr. Tim Brown 12/12/2009 08:47 PM * PREMIUM MEMBER - Real Name
Thanks Pete,
No doubt Dr Sarno . The mind/emotions can effect health dramatically. But in my experience you must still train for core stability, posture, balance and function. Mobility and stability is necessary to perform efficient, quality movements that create awareness and fine tune the communication between your nervous system and your muscles...research shows the connection between what you eat, what you think and what you do, relative to your health and function is quantifiable. Dr TB
Dr. Tim Brown 12/12/2009 08:31 PM * PREMIUM MEMBER - Real Name
Yunen,
We will be doing a full feature on the shoulder v soon. Thanks for lookin out. Dr TB
Jim Philipp 12/03/2009 08:53 AM
WOW! Great article. Being over sixty and still surfing Oahu's No. Shore requires a regimen of yoga type stretching daily. Doing Yoga with a group is much more energizing and satisfying than by one's self.
Surfmore 11/30/2009 05:14 PM * PREMIUM MEMBER - Nickname
Where does one go to find a Healthcare practitioner who specializes in Functional vs. Structural care? The same questions applies to finding a trainer or gym that follows the Surfline Health + Fitness approach. Any reccomendations for professionals in South OC?
Pete Fletcher 11/30/2009 12:52 PM * PREMIUM MEMBER - Real Name
All i got to say is Doc Paskowitz.......just go surf ive got herniated discs and some days i cant even move but surfing loosens my muscles in my back more than anything than the chiropractor can do. i feel better physically better after a skate or surf just keep moving thats what helps me and the days it raining or i cant do my hobbies the pains get worse.
Michael Deese 11/30/2009 12:02 PM * PREMIUM MEMBER - Real Name
Woody, For hip flexors, you need to do lunges. Look up Dr. Jolie Bookspan on Google to see the stretch on her website. The hip stretching is one of the most important muscles to stretch daily, especially if you have a desk job and sit a lot. The hip muscle shortens and pulls the lower back out.
PR 11/30/2009 06:17 AM
yoga?!?
Stephen Wolfram 11/30/2009 04:42 AM * PREMIUM MEMBER - Real Name
Any yoga-based exercises (like Pilates) will work. After going over the falls at Sandy Beach I crawled out of the water and was numb from the chest down, thank god I only had a L2 compression fracture. I have found relief from chronic pain through yoga. Much love to all my fellow-back-pain sufferers, it is a daily struggle, and there are good days and bad days. Peace.
Andrew 11/29/2009 10:00 PM
My girl friend has bad scoliosis which obviously affects her flexibility and stamina when surfing and gives her pain sometimes.
She does physio exercises every day which really helps but I worry about long term problems. She is only 21.
Have you got any insight to scoliosis and what is a good long term approach to managing this? Thanks
Joshua Malpass 11/29/2009 08:45 PM
Fantastic article Tim, thanks for blessing us with your knowledge
yaya 11/29/2009 07:24 PM
the article is very helpful. could we get some photos of the stretches? or video? it would explain it better than words
Brett Sizemore 11/29/2009 06:24 PM
View All Comments (23 comments)
I've got a c4-C7 titanium plate and eight screws and as a result of Dr. Delamarter at St John's in Santa Monica, pushed myself to become a certified personal fitness trainer. We have amazing possibilities nowadays. Thanks for the continued motivation Tim.
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